COMPLIANCE INFO_FILE 10 - Laserfiche WebLink

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RUCTIONS FOR COMPLVIING.FORM"B" GENERAL INSTRUCTIONS: 1. One FORM"B"shall be completed for each tank for all NEW PERMIMS,PERMIT CIIANGI S, REMOVALS and/or any other TANK INFORMA11ON CHANGE. 2. This form should be completed by either the PERMPT APPLICANT or the LOCAL AGENCY UNDERGROUND .TANK INSPECTOR. 3. Please type or print clearly all requested information. 4. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM.'MARK ONLY ONE MW* 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 2. Indicate the DBA or Facility name where the tank is installed. I. TANK DESCRIPTION-COMPL UME All,n77MS-IF UNKNOWN-SO SPECIFY A. Indicate owners tank ID#- If there is a tank number that is used by the owner to identify the tank(ex.AB70789). B. Indicate the name of the company that manufactured the tank(ex.ACME"TANK MFG.). C. Indicate the year the tank was installed(ex. 1987). D. Indicate the tank capacity in gallons(ex.25,000 or 10,(M etc.). H. TANK CONFF.NTS A. 1. If.MOTOR VEIfICL,E FUEL,check box 1 and complete items B &C. 2. If not MOTOR VEHICLE FUI:I.,check the appropriate box in section A and complete items B &D. B. Check the appropriate box. C. Check the type of MOTOR VEHICLE FUEL(if box 1 is checked in A). I). Print the chemical name of the hazardous substance stored in the tank and the C.A.S.#. (Chemical Abstract Service number), if box 1.is NOT checked in A. 111. 'TANK CONSI'RUCI'ION-MARK ONE 111W ONLY IN BOX A,Il,C&D 1. Check only one item in'.TYPE OF SYSTEM,TANK MATERIAL,INTERIOR I.,INING and CORROSION PROTEC`T'ION. 2. If OTHER,print in the space provided. N. PIPING INFORMATION 1. Circle if above ground;circle U if underground;and circle both if applicable. 2. If UNKNOWN,circle; or if OTHER,print in space provided. 3. Indicate the LEAK DE.-IMC-110N system(s)used to comply with the monitoring requirement for the piping. V. TANK LEAK.113E11:MON 1. Indicate the LEAK DE"ITCTION system(s)used to comply with the monitoring requirements for the tank. VI. INFORMATION ON TANK PE:RMANFN[1,Y CLOSED IN PLAC'E? L E5I71NINfED DA'L'E LAST USED-MONTII/YEAR(January, 1.988 or 01/88). 2. ESTIMATED QUANTITY of HAZARDOUS SUBSTANCE remaining in the tank (in Gallons). 3. WAS TANK PILLED WITH IM3RT MAI:'ERIAL?Check'Yes'or'NO'. APPIdCANC MUST SIGN AND DATE TME FORM AS INDICA1111 INSTRUCTION FOR 11IE LOCAL.AGENCIES "The state underground storage tank identification number is composed of the two digit county number, the three digit jurisdiction number,the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2421.. The facility number must be the same as shown in form "A". The tank number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the tank number,please leave it blank. PT IS TIIE RESPONSIBIL.X17Y OF TILS?LOCAL AGFNCY'THAT INSPIX71S IHE FACIL n Y TO VERIFY 111E ACCURACY OF 111E INFORMA110N. I'IIE LOCAL AGENCY IS RESPONSIBLE FOR'111E C:OMPLUITON OF THE "LOCAL AGENCY USE ONLY'L.NFORMAIION BOX AND FOR FORWARDING ONE DORM A"AND AS.SC CI)VIVD FORM*B"(s)TO TILE FOLLOWING ADDRESS. SCATS OF CALIFORNIA SPATE WAn.,.R RFSOURCI?S'CONFROL BOARD C/O S.W.I.+ILP.S. DAI'A PROCESSING CEMI'ER. P.O.BOX 527 PARAMOUNT,CA 99M At .�. •r t.. w.+,;�yr•�., .�_ }> .........xF�z-Y[3 ,'*1Kdis_�4: .